0920-1348 NFR Enrollment Questionnaire
National Firefighter Registry
Comments_Attachment 3c. Questionnaire
OMB: 0920-1348
Attachment 3c. Questionnaire
Form Approved OMB
No. XXXX Exp. Date
xx/xx/20xx
CDC estimates the average
reporting burden for this collection of information as 30 minutes
per response, including the time for reviewing instructions,
searching existing data/information sources, gathering and
maintaining the data/information needed, and completing and
reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestion for
reducing the burden to CDC/ATSDR Information Collection Review
Office, 1500 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:
PRA (0920-XXXX).
National
Firefighter Registry (NFR)
Enrollment Questionnaire
Demographics
First Name ______(auto-populates from user profile)__________________
Middle Name_____(auto-populates from user profile) _________________
Last Name_______(auto-populates from user profile) _________________
Employee ID/Departmental Identification for current or most recent position
Date of Birth ____ ____ month ____ ____ day __ __ __ __ year
Country of Birth __________City of Birth ______________ State of Birth _______
What sex were you assigned at birth, on your original birth certificate?
Male
Female
Ethnicity- Are you Hispanic or Latino?
Yes, I am Hispanic or Latino
No, I am not Hispanic or Latino
Race- select one or more
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Marital status
Married
Living with a partner as an unmarried couple
Never married
Divorced
Separated
Widowed
Other
Please Specify
Prefer not to answer
What is your height? _____ feet ______inches
What is your current weight? _______ pounds (if pregnant, please report pre-pregnancy weight)
In the United States, each state has a cancer registry that collects and combines information on all cancer diagnoses from all hospitals in that state. Providing the last four digits of your social security number (SSN) will increase the likelihood of linking your profile and questionnaire information to any past or potentially future cancer diagnosis reported to a state. This information is necessary to meet the statutory requirements of the Firefighter Cancer Registry Act of 2018. You can choose to provide this information or not. As noted on the informed consent, all your private information will be encrypted, secured, and protected to the fullest extent allowed by law.
SSN: XXX-XX-__ __ __ __ (link: why are we asking this?)
[Pop-up box if user clicks “why are we asking this”]
Why are we asking for this?
We need to track firefighters’ health over time to truly understand their cancer risks and improve their protections. Sharing the last four digits of your social security number will let us do this by linking your information to state cancer registries. With this information we can see any potential future cancer diagnosis without any further action from you. Each firefighter that shares this information will increase the accuracy of our findings, which could potentially lead to greater protections for all firefighters. Sharing the last four digits of your social security number will ensure your participation has the maximum impact.
We will protect your information to the fullest extent allowed by law. The National Firefighter Registry is covered by an Assurance of Confidentiality, which is the highest level of protection available for identifiable information. Under this formal protection, we are not allowed to share your identifiable information without your written permission.
Confirm SSN: XXX-XX-__ __ __ __
Work and Exposure History
Please answer the following questions on your work history. Please include both volunteer and paid work when answering these questions.
What is the total amount of time that you have worked in the fire service?
_____years OR______ months
In what year did you first work as a firefighter? __ __ __ __
How many fire departments or agencies have you worked at? [dropdown menu with numerical choices ranging from 1-20] _________
Please answer the following questions for each of these X departments/agencies/organizations beginning with the most recent [X auto-populated with response from question 16]
1st department/agency/organization: [auto-populates with department name listed in user profile]
What state is this department, agency, or organization located in? (drop down list of US states and territories and “Outside U.S.”) (auto-populated from user profile)
Name of department, agency, or organization? [scrolling menu from state selection] _________________ (auto populated from user profile)
If not listed, please fill-in department name____________________
(if department matches fields in fire department database, a pop-up will ask “did you mean __________ department?”
[If manually entered] What jurisdiction do/did you serve at this department, agency, or organization? (dropdown menu, select all that apply)
Federal
Military
Municipal/City
Municipal/County
Municipal/District
Private
Tribal
Other
[if other, please describe] ________________________
Approximately what year did you start working at X department/agency/organization (auto-populated)? [Fill-in 4 digit year]__ __ __ __]
Approximately what year did you stop working at X department/agency/organization (auto-populated): [Fill-in 4 digit year or select current/present] __ __ __ __
Tell us about the job titles you’ve held at X department/agency/organization- select all that apply
Structural or Industrial Firefighter
As a structural firefighter, which roles most closely apply/applied to you? (select all that apply)
Firefighter
Firefighter Medic
Firefighter EMT
Firefighter AEMT
Firefighter Paramedic
Driver/Engineer/Operator
Wildland Firefighter
As a wildland firefighter, which roles most closely apply/applied to you? (select all that apply)
Engine crew
Hand crew
Line medic
Base camp support staff
Smokejumper
Aviation Crew (Flight or Ground)
Company Officer (Lt, Cpt, Sgt)
Wildland Supervisor or Overhead
Chief (select all that apply)
Fire Chief/Commissioner
Battalion/District Chief
Assistant Chief
Deputy Chief
Division Chief
Fire Investigator, where this is your primary job assignment
Instructor, where this is your primary job assignment
Superintendent/Crew Boss
EMT/Paramedic, where this is your primary job assignment
Fire Marshall
Other
Please specify
What best describes your position at this fire department, agency, or organization?
Full time
Part time
Volunteer
Seasonal
Paid on call or paid per call
Other
[if other, please specify] _________________________________
As a (Job title X auto filled with information provided above) at X department/agency/organization, (both department/agency/organization and job title will be auto filled with response from first part of Q17):
Approximately what year did you start working in this position: [Fill-in 4- digit year] __ __ __ __
Approximately what year did you stop working in this position? [Fill-in 4-digit year or select current/present] __ __ __ __
Did you respond to fires during your time as X (job title auto-populated with information above? (Yes/No) (dropdown menu)
No
Yes
Please estimate the average total number of fires you actively worked in a typical year in this position. Include only fire incidents where smoke and flames were present. [fill in with numerical values only] _______
Please estimate the average number of incidents you actively responded to in a typical year as X for each category below (auto-populates with job title)
Aircraft Rescue [dropdown menu]
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Water Vehicle Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Fire Investigation (post-extinguishment)
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
HAZMAT Response/Spill
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Industrial Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Structural Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Live-Fire Training/Instruction
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Vehicle Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Outside Rubbish Fires or Dumpster Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Vegetation/Brush Fires (not including wildland fires)
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
Wildland Fires or Wildland Prescribed Burns
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
On average, approximately how many days do you/did you spend actively responding to wildland fires in a year? ________
Wildland Urban Interface Fires
[fill in with numerical values only] __________
I’ve responded to this, but less than once per year
I do not/did not respond to this type of fire
[*The above loop of questions (question 17) will repeat for the number of job positions a participant has reported working in the 1st department]
Tell us more about your second most-recent department/agency/organization.
2nd department/agency/organization: Question 17 pattern will repeat for number of departments/agencies/organizations reported in question 16.
Have you implemented the following practices on a regular basis (most of the time) at any point in your career?
Wear SCBA during interior fire attack of a structural/industrial fire
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA during external fire attack of a structural/industrial fire
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during overhaul of a structural/industrial fire
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during vehicle fires
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA, an air purifying respirator with multi-chemical canister/cartridge, or filtering facepiece respirator (example, N95 mask) during brush or vegetation fires
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear air purifying respirator with multi-chemical canister/cartridge or filtering facepiece respirator during wildland fire suppression
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA, air purifying respirator with multi-chemical canister/cartridge, or filtering facepiece respiratory (example, N95 mask) while performing or attending fire investigations
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear SCBA or air purifying respirator with multi-chemical canister or cartridge when responding to wildland-urban interface fires
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wear a protective hood during interior fire response
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Not applicable
Conduct preliminary exposure reduction of my PPE (on-scene gross decon of turnout gear)
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Keep used PPE out of passenger compartment of vehicle
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wash/wipe down equipment (radio, SCBA, tools, etc)
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Wash or clean my hands on-scene before taking in food or drink
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Clean your exposed skin on-scene after a fire response (use skin wipes or other cleansing method)
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Prioritize showering as quickly as possible following fire response (for example, “shower within the hour”)
Yes
What year did you start doing this regularly? [dropdown menu with year options]
No
Have hood laundered after every or almost every fire response?
Yes
[If selected] Approximately what year did you regularly begin following this practice? (dropdown menu with year options)
No
[if “no” selected] Approximately how frequently do you/did launder your hood?
Every 1-2 weeks
Every 1-2 months
Quarterly (4 times a year)
Twice a year
Annually
Less than once a year
Never
[If selected any option other than never] Approximately what year did you regularly begin following this practice? (dropdown menu with year options including N/A)
N/A- I do not wear a hood
Have turnout gear or other fire-response clothing laundered after every or almost every fire response?
Yes
[If selected] Approximately what year did you regularly begin following this practice? (dropdown menu with year options)
No
[if “no” selected] Approximately how frequently do you/did launder your turnout gear or other fire-response clothing?
Every 1-2 weeks
Every 1-2 months
Quarterly
Twice a year
Annually
Less than once a year
Never
[If selected any option other than never] Approximately what year did you regularly begin following this practice? (dropdown menu with year options including N/A)
How do you/did you launder your PPE [not asked to those who respond “never” to question above]
Take it home
Send out via contracted service
Wash it at the station
Take to a laundromat
Department central location (example, Headquarters, Shop, Quartermaster, etc.)
Other
[If other] Please explain _______________
Have you ever served in the U.S. Armed Forces or other uniformed services?
Yes
Are you currently serving?
Yes
No
Did you ever serve in a combat or war zone?
Yes
No
No, never served in the U.S. Armed Forces or other uniformed services
Have you ever held another job for 6 months or more while also working in the fire service?
No
Unsure
Yes
For your job that overlapped with your fire service career the longest...
What kind of work do/did you do? (for example, registered nurse, janitor, cashier, auto mechanic) ______________ (fill-in, open text)
What kind of business or industry do/did you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant) _______ (fill-in, open text)
What year did you begin that job? [year – numerical fill-in]
Are you currently employed in that job?
No
What year did you end that job? [year – numerical fill-in]
Yes
Over your lifetime, have you ever held a non-firefighting job (or jobs) for at least 100 days or more where you were routinely exposed to smoke, exhaust, or chemicals?
No
Unsure
Yes
Please answer the next group of questions based on your current (for current firefighters) or most recent assignment (for former/retired firefighters).
What is/was your typical shift configuration?
24 hours on/24 hours off
24 hours on/48 hours off
24 hours on/72 hours off
48 hours on/96 hours off
24 hours on/24 hours off/24 hours on/24 hours off/24 hours on/4 days off
72 hours on/96 hours off
9 hours on/15 hours off
10 hours on/14 hours off
10 hours, 4 days per week
12 hours on/12 hours off
8 hours on/5 days per week
5-6 (5-24 hour shifts, 6 days off)
On-call
Volunteer, on-call continuously
Wildland, seasonally deployed
Other
[If other] Please specify ________________
On average, how many calls do you/did you run in a shift?
[dropdown with numerical options starting with 0] _____________
I don’t operate on shift
On average, how many hours of uninterrupted sleep do you/did you get in a 24-hour period when on duty or on call?
[numerical fill-in] _____________
On average, how many hours of uninterrupted sleep do you/did you get in a 24-hour period when you are not/were not on duty or on call?
[numerical fill in] _____________
Throughout your entire career, have you ever used Aqueous Film-Forming Foam (AFFF)?
No
Yes
Approximately how many times have you used AFFF (please include all uses such as training, fire suppression, maintenance, etc.)? (numerical fill in) _________
Throughout your career, have you responded to any major events that you would consider unusual in duration or intensity? These events could include: natural disasters, acts of terrorism, industrial events, extreme wildland disasters, etc.
No
Yes
Prefer not to respond
[If yes] Approximately how many times have you responded to a major event? [dropdown menus with numerical options starting at 1] _________
Event 1: How would you classify the first event? [repeats for each event]
Natural disaster
Chemical
Industrial/Factory
Wildland
Vegetation
Structural
Terrorist event
Other
[If other] Please specify ______________________
Approximately how long did this event last? [repeats for each event] _______days OR [dropdown menu for days] ________ hours [dropdown menu for hours]
Was this a named event? (example, 9/11, Hurricane Katrina) [repeat for each event]
Event 2: How would you classify the second event? [repeats for each event]
Natural disaster
Chemical
Industrial/Factory
Wildland
Vegetation
Structural
Terrorist event
Other
[If other] Please specify ______________________
Approximately how long did this event last? [repeat for each event]
Was this a named event? (example, 9/11, Hurricane Katrina) [repeat for each event]
No
Yes
[If yes] What was this event commonly known as? _______
Lifestyle
We are asking about lifestyle behaviors because cancer or other health conditions may be related to a combination of work events and lifestyle choices.
In a typical week, do you perform physical activity that raises your heartrate (such as swimming, biking, brisk walking, jogging, rowing) for at least 150 minutes (2 hours and 30 minutes) per week not including firefighting response activities?
Yes
No
Prefer not to answer
In a typical week, do you perform weight or strength training at least 2 days a week?
Yes
No
Prefer not to answer
After several months of not being in the sun, if you then went out into the sun without sunscreen or protective clothing for one hour, which of these would happen to your skin?
Get a severe sunburn with blisters
Have a moderate sunburn with peeling
Burn mildly with some or no darkening/tanning
Turn darker without sunburn
Nothing would happen to my skin
Do not go out in the sun
How many blistering sunburns have you had in your lifetime?
0
1-5
6-10
10 or more
In your entire life, have you smoked 100 or more cigarettes (note, five packs is equal to 100 cigarettes)?
Prefer not to answer
No
Yes, I currently smoke cigarettes
On average, about how many cigarettes a day do you smoke? (numerical fill-in)
At what age did you first start smoking regularly? (numerical fill-in)
How many years have you smoked, not counting time periods when you had quit? (numerical fill-in)
Yes, I formerly smoked cigarettes
On average about how many cigarettes a day did you smoke? (numerical fill-in)
At what age did you first start smoking regularly? (numerical fill-in)
How many years did you smoke, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last smoked cigarettes?
Did you ever use smokeless tobacco, such as chewing tobacco, snuff, or dip regularly for a year or longer?
Prefer not to answer
No
Yes, I currently use smokeless tobacco regularly
On average, about how many dips per day do you use? (numerical fill-in)
At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
How many years have you used smokeless tobacco, not counting time periods when you had quit? (numerical fill-in)
Yes, I formerly used smokeless tobacco regularly
On average about how many dips per day did you use? (numerical fill-in)
At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
How many years did you use smokeless tobacco, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last used smokeless tobacco?
Did you ever smoke cigars regularly for a year or longer?
Prefer not to answer
No
Yes, I currently smoke cigars regularly
At what age did you first start smoking cigars regularly? (numerical fill-in)
How many years have you smoked cigars, not counting time periods when you had quit?
Yes, I formerly smoked cigars regularly
At what age did you first start smoking cigars regularly? (numerical fill-in)
How many years did you smoke cigars, not counting time periods when you had quit?
How old were you when you last smoked cigars?
Did you ever smoke pipes regularly for a year or longer?
Prefer not to answer
No
Yes, I currently smoke pipes regularly
At what age did you first start smoking pipes regularly? (numerical fill-in)
How many years have you smoked pipes, not counting time periods when you had quit?
Yes, I formerly smoked pipes regularly
At what age did you first start smoking pipes regularly? (numerical fill-in)
How many years did you smoke pipes, not counting time periods when you had quit?
How old were you when you last smoked pipes?
Did you ever vape or use e-cigarettes regularly for a year or longer?
Prefer not to answer
No
Yes, I currently vape or use e-cigarettes regularly
At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
How many years have you vaped or use e-cigarettes, not counting time periods when you had quit?
Yes, I formerly vaped or used e-cigarettes regularly
At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
How many years did you vape or use e-cigarettes, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last vaped of used e-cigarettes?
In the past 30 days, how many days did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. [dropdown with numerical options starting with 30] _____________
[If 0, skip questions 37-38]
During the past 30 days, on the days when you drank, how many drinks did you consume on average? [fill-in, numerical text] __________
Considering all types of alcoholic beverages, how many times in the past 30 days did you consume 4/5 or more drinks on an occasion? [4 will appear for women, 5 will appear for men or missing sex response] [dropdown with numerical options starting with 30 and going down to 0] __________
Has a health professional ever told you to consider reducing your alcohol use?
Yes
No
Unsure
Prefer not to answer
Health History
How often do you get an NFPA 1582 compliant or other comprehensive occupational physical exam?
Annually
Once every 2-3 years
I do not routinely have an occupational physical exam
Prefer not to answer
How often do you see a health care provider for a routine check-up?
Annually
Once every 2-3 years
I do not see a health care provider routinely
Prefer not to answer
[ask to participants age 40+] There are different kinds of tests to check for colon or rectal cancer, including colonoscopy, sigmoidoscopy, and stool-based tests. Have you ever had a test to check for colon or rectal cancer?
Yes
[If yes] Approximately how old were you when you had your first test to check for colon or rectal cancer? (numerical fill-in)
[If yes] About how long has it been since your most recent test to check for colon or rectal cancer?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to males age 40+] A PSA is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test. Have you ever had a PSA test?
Yes
[If yes] Approximately how old were you when you had your first PSA test? (numerical fill-in)
[If yes] How long has it been since your most recent PSA test?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to females age 25+] There are two different kinds of tests to check for cervical cancer. One is a Pap smear or Pap test and the other is the HPV or Human Papillomavirus test. Have you ever had a test to check for cervical cancer?
Yes
[If yes] Approximately how old were you when you had your first test to check for cervical cancer? (numerical fill-in)
[If yes] When did you have your most recent test to check for cervical cancer?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to females age 30+] A mammogram is an x-ray taken only of the breast by a machine that presses against the breast. Have you ever had a mammogram?
Yes
[If yes] Approximately how old were you when you had your first mammogram? (numerical fill-in)
[If yes] How long has it been since your most recent mammogram?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
Have you ever been diagnosed with cancer?
No
Unsure if I have ever been diagnosed with cancer
Yes
[If yes] What type(s) of cancer were you diagnosed with? Please select where the cancer(s) started (primary site):
Bladder
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Brain or Central Nervous System
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Breast
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Cervix
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Colon or Rectum
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Esophagus
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Hodgkin's Lymphoma
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Kidney
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Leukemia
[if selected] What type of leukemia were you diagnosed with?
Acute myeloid (or myelogenous) leukemia (AML)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Chronic myeloid (or myelogenous) leukemia (CML)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Acute lymphocytic (or lymphoblastic) leukemia (ALL)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Chronic lymphocytic leukemia (CLL)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Other or Unsure
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Liver
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Lung
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Mesothelioma
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Multiple Myeloma
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Non-Hodgkin's Lymphoma
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Ovary
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Pancreas
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Prostate
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Skin: Melanoma
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Small Intestine
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Stomach
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Testis
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Thyroid
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Uterus/Endometrium
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Unsure which cancer (primary site)
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Other type of cancer
Please specify: ______
[if selected] What was your age when first diagnosed? _ _ (fill-in)
In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)
Have you ever been told by a healthcare professional that you have the following conditions?
Diabetes
No
Yes
If yes, what type?
Type 1
Type 2
Gestational
Unsure
High Blood Pressure
No
Yes
High Cholesterol
No
Yes
Overweight
No
Yes
Obesity
No
Yes
Rheumatoid Arthritis
No
Yes
Asthma
No
Yes
Emphysema
No
Yes
Chronic Bronchitis
No
Yes
Heart Disease (e.g. heart attack, heart failure, atherosclerosis)
No
Yes
Stroke
No
Yes
Sleep Apnea
No
Yes
Insomnia
No
Yes
Celiac Disease
No
Yes
Inflammatory bowel disease
No
Yes
If yes, what type?
Crohn’s Disease
Ulcerative Colitis
Unsure
Other
Please specify
Colorectal Polyps
No
Yes
Chronic Hepatitis (Hepatitis B, Hepatitis C)
No
Yes
Post-Traumatic Stress Disorder
No
Yes
Depression
No
Yes
Anxiety
No
Yes
Dementia
No
Yes
Traumatic Brain Injury (concussion)
No
Yes
Coronavirus Disease 2019 (COVID-19)
No
Yes
Have you ever experienced an injury resulting in 3 or more days away from work?
No
Yes
Have you ever experienced a smoke inhalation injury resulting in the need for medical care (such as emergency department visit or health professional consultation)?
No
Yes
Do any of your biological children have a history of cancer?
I do not have any biological children
Unsure if my biological children have a history of cancer
No
Yes
[If yes] Where did the cancer(s) start (primary site)? Select all that apply:
Unsure
Bladder
Brain or Central Nervous System
Breast
Cervix
Colon or Rectum
Esophagus
Hodgkin's Lymphoma
Kidney
Leukemia
Liver
Lung
Mesothelioma
Multiple Myeloma
Non-Hodgkin's Lymphoma
Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
Ovary
Pancreas
Prostate
Skin: Melanoma
Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown
Small Intestine
Stomach
Testis
Thyroid
Uterus/Endometrial
Unsure which cancer (primary site)
Other
Please specify: _____
Do you have a family history of cancer among your other immediate biological (blood) relatives, including mother, father, and/or sibling(s)?
Unsure if I have a family history of cancer
No
Yes
[If yes] Where did the cancer(s) start (primary site)? Select all that apply:
Unsure
Bladder
Brain or Central Nervous System
Breast
Cervix
Colon or Rectum
Esophagus
Hodgkin's Lymphoma
Kidney
Leukemia
Liver
Lung
Mesothelioma
Multiple Myeloma
Non-Hodgkin's Lymphoma
Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
Ovary
Pancreas
Prostate
Skin: Melanoma
Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown
Small Intestine
Stomach
Testis
Thyroid
Uterus/Endometrial
Unsure which cancer (primary site)
Other
Please specify: _____
If answer to sex on question 9 is female (males will not see these questions): Have you ever been pregnant?
No
Yes
If yes, how many times have you been pregnant? (numerical fill-in)
How many of your pregnancies resulted in at least one live birth? (numerical fill-in)
How old were you when your first pregnancy occurred? (numerical fill in, unsure, prefer not to answer)
Have you ever breastfed?
No
Yes
Approximately how many months did you breastfeed in total for all births combined? ____months (numerical fill-in)
Prefer not to answer
Unsure
Prefer not to answer
How old were you when you had your first menstrual period? (numerical fill-in) ______________
Have never had a menstrual period
Unsure
Prefer not to answer
Has it been 12 months or more since you had your last menstrual period?
No
Yes
How old were you when you had your last period? (numerical fill-in and unsure)
Why did your menstrual periods stop?
Currently pregnant or nursing
Menstrual periods stopped naturally
Surgery (e.g., hysterectomy or oophorectomy)
Chemotherapy treatments
Hormonal contraceptives (pill, shot, patch, intrauterine device, etc.)
Unsure
Other
Please specify ______________
(If yes to 50 Have you used any female hormones for two months or more to treat hot flashes or other menopausal symptoms (such as Premarin or other estrogens)?
No
Yes
How old were you when you began using these medications? (numerical fill-in and unsure)
Altogether, for how many months or years in total have you used these medications? (numerical fill-in and unsure) ____months OR ______years
How old were you when you stopped using these medications? (numerical fill-in)
Currently using
Unsure
N/A
Unsure
Prefer not to answer
Have you ever used hormonal contraceptives for two months or more for any reason (contraception, acne, menstrual irregularity, endometriosis, polycystic ovarian syndrome, etc.)?
No
Yes
How old were you when you began using hormonal contraceptives? (numerical fill-in)
Altogether, for how many months or years have you used hormonal contraceptives? (numerical fill-in) ______months OR _______years
How old were you when you stopped using hormonal contraceptives? (numerical fill-in)
Currently using
Unsure
Prefer not to answer
You have reached the end of this survey, and we would like to offer you an opportunity to give us feedback:
Is there anything else you would like us to know? [narrative box]
Thank you for your participation in the National Firefighter Registry. If you have questions, please feel free to email us at [email protected] or call _____________.
Submit
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| File Modified | 0000-00-00 |
| File Created | 2022-07-25 |
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